Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 1 of 12 CME ACTIVITY Prevalence of Self-Reported Sleep Problems Among People With Diabetes in the United States, 2005-2008 Laura Plantinga, ScM; Madhu N. Rao, MD; Dean Schillinger, MD Suggested citation for this article: Plantinga L, Rao MN, Schillinger D. Prevalence of self-reported sleep problems among people with diabetes in the United States, 2005-2008. Prev Chronic Dis 2012;9:110244. DOI: http://dx.doi.org/10.5888/pcd9.110244 . MEDSCAPE CME Learning Objectives Medscape, LLC is pleased to provide online Upon completion of this activity, participants will be able to: continuing medical education (CME) for this journal article, allowing clinicians the opportunity to earn Describe the overall prevalence of sleep problems CME credit. among persons with diabetes as based on 2005-2008 This activity has been planned and implemented in NHANES data. accordance with the Essential Areas and policies of Describe factors modifying the prevalence of sleep the Accreditation Council for Continuing Medical problems among persons with diabetes as based on Education through the joint sponsorship of 2005-2008 NHANES data. Medscape, LLC and Preventing Chronic Disease. Medscape, LLC is accredited by the ACCME to provide Describe the prevalence of specific sleep problems continuing medical education for physicians. among persons with diabetes as based on 2005-2008 NHANES data. Medscape, LLC designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit CME EDITOR commensurate with the extent of their participation Nancy Saltmarsh, Editor, Preventing Chronic Disease. in the activity. Disclosure: Nancy Saltmarsh has disclosed no relevant financial relationships. All other clinicians completing this activity will be issued a certificate of participation. To participate in CME AUTHOR this journal CME activity: (1) review the learning Laurie Barclay, MD. Freelance writer and reviewer, objectives and author disclosures; (2) study the Medscape, LLC. Disclosure: Laurie Barclay, MD, has education content; (3) take the post-test with a 70% disclosed no relevant financial relationships. minimum passing score and complete the evaluation at www.medscape.org/journal/pcd ; (4) view/print AUTHORS certificate. Disclosures: Laura Plantinga, ScM; Madhu N. Rao, MD; and Dean Schillinger, MD, have disclosed no relevant financial Release date: March 22, 2012; Expiration date: relationships. March 22, 2013 PEER REVIEWED Abstract Introduction Sleep problems, including insomnia, apnea, and restless legs syndrome, are common, burdensome, and under- recognized in the United States. We sought to examine the association of sleep problems with diabetes among community-dwelling US adults. Methods We examined self-reported sleep problems in 9,848 adults (aged ≥20 y) participating in the National Health and Nutrition Examination Survey 2005 through 2008. Sleep problem information was elicited via validated questionnaire. Diabetes was defined by self-reported diagnosis or glycohemoglobin of 6.5% or higher. Multivariable logistic regression Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 2 of 12 with US population-based weighting was used to obtain adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for various sleep problems by diabetes status. Results Sleep problems were common (>90% for any problem; 10%-40% for individual problems) overall, and people with diabetes were more likely than those without diabetes to report multiple problems (mean, 3.1 vs 2.5, respectively, P < .001). After adjustment for potential confounders (including demographics, body mass index, cardiovascular and kidney disease, and alcohol use), restless legs symptoms (OR, 1.40; 95% CI, 1.12-1.78), sleep apnea (OR, 1.45; 95% CI, 1.06-1.98), and nocturia (OR, 1.51; 95% CI, 1.22-1.87) were all positively associated with diabetes status. Conclusion Diabetes is associated with a higher risk of sleep problems, including not only sleep apnea but also inadequate sleep, excessive sleepiness, leg symptoms, and nocturia, independent of body mass index. Clinicians should be aware of the high prevalence of sleep problems among their patients with diabetes and should consider screening and treatment, which may improve patients’ quality of life. Introduction One-third of US adults report inadequate sleep (1). Sleep problems are associated with cardiovascular disease (2), mental health problems (3), motor vehicle accidents (4), and overall poor quality of life (5). The direct and indirect costs of sleep problems are substantial (6). Despite the individual and societal burden of sleep problems, most (80%-90%) remain undiagnosed (7). Both diabetes (8) and sleep problems (5) are highly correlated with poor quality of life. People with diabetes may also be at higher risk for sleep problems relative to the general population because of common risk factors for diabetes and sleep problems, including advanced age, obesity, and treatments for and complications of common comorbid diseases (eg, depression, cardiovascular disease). Additionally, diabetes-specific complications, such as neuropathy, could directly interfere with sleep. However, because of low rates of detected sleep disorders (7), most people with diabetes who have sleep problems are likely to go untreated. Thus, estimating the prevalence of such undiagnosed sleep problems can help determine whether these problems are a public health concern. Although there are more than 80 recognized sleep disorders (9), studies of diabetes and sleep have focused mainly on sleep apnea (10). Additionally, most studies of diabetes and sleep problems have lacked comparisons to the general population and have depended on the diagnosis of sleep disorder. We sought to examine the association of self-reported sleep problems — which are likely to be more prevalent than diagnosed sleep disorders — with diabetes among community-dwelling US adults, using data from the National Health and Nutrition Examination Survey (NHANES) 2005 through 2008. We focused on the most common sleep problems: sleep apnea, insomnia, nocturia, and leg symptoms. Methods Study design NHANES is conducted by the Centers for Disease Control and Prevention (CDC) and consists of a standardized in-home interview followed by a physical examination at a mobile examination center. NHANES uses representative samples of noninstitutionalized US civilian residents. We limited our analysis to NHANES 2005 through 2008 adult (≥20 y) participants who responded to the sleep questionnaire and completed the examination (n = 9,848). NHANES 2005 through 2006 and 2007 through 2008 reported response rates of 77.4% and 75.4% for the examined participants, respectively. All participants gave written informed consent. The National Center for Health Statistics Research Ethics Review Board approved the protocol. Measurements Questionnaire Interviewers administered a questionnaire pertaining to sleep habits and sleep-related problems (www.cdc.gov/nchs/data/nhanes/nhanes_05_06/sp_slq_d.pdf), including items from 2 validated instruments: the Sleep Heart Health Study Sleep Habits Questionnaire (11) and the Functional Outcomes of Sleep Questionnaire (12). We have described individual items previously (13). Nocturia was an item on a separate kidney conditions – urology questionnaire (www.cdc.gov/nchs/data/nhanes/nhanes_05_06/sp_kiq_d.pdf). Participants self-reported demographics (age, sex, race/ethnicity), socioeconomic status and health care access (education, income, and health insurance coverage), and health status and conditions (diagnosis of diabetes, hypertension, and cardiovascular disease [CVD]; smoking and alcohol use; and depressive symptoms from the Patient Health Questionnaire-9 [PHQ-9] [14]) via questionnaire. The interviewer recorded prescription medications from the bottles provided by the participant. Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 3 of 12 Examination and laboratory measurements Laboratory personnel performed glycohemoglobin measurements using a high-performance liquid chromatography system and assessed fasting plasma glucose concentration by a hexokinase method. Laboratory personnel also measured serum and urine creatinine by the modified kinetic method of Jaffe and urine albumin using solid-phase fluorescence immunoassay. Examination personnel recorded anthropomorphic measurements (weight and height, used to calculate body mass index [BMI]) and blood pressure (≥3 auscultatory measurements). Definitions Sleep problems We used inadequate sleep, sleep deprivation, daytime sleepiness, and sleeping pill use as markers of insomnia. We defined inadequate sleep as less than 7 total hours of sleep, according to National Sleep Foundation guidelines (15) (Box); we defined excess sleep as 9 or more hours per night. We defined severe sleep deprivation by sleep onset latency 5 minutes or less (16). We considered daytime sleepiness and sleeping pill use to be frequent if they were reported “often” or more (≥5 times/mo). We defined apnea by frequent self-reported apnea, snorting, or gasping, or diagnosed sleep apnea. We defined nocturia as reported urination of 2 or more times per night. We included frequent self-reported leg jerks or cramps, or diagnosed restless legs syndrome as leg symptoms (Box). Diabetes Box. Definition and Measurement of Sleep We defined diabetes by self-report (answer of yes to the Problems, NHANES, 2005-2008 question, “Other than during pregnancy, have you ever Problem Questionnaire Possible Definition been told by a doctor or other health care provider that Itema Responses you have diabetes or sugar diabetes?”) or glycohemoglobin of 6.5% or more (17). We did not Inadequate How much Any <7 h include fasting plasma glucose of 126 mg/dL or more in sleep sleep do you number of the main definition because of the small sample of usually get at hours with fasting morning participants (n = 4,770). night on upper limit weekdays or of 12 Other definitions workdays? Severe How long does Any ≤5 min We defined self-reported diseases by answers of yes to sleep it usually take number of the question, “Have you ever been told by a doctor or deprivation you to fall minutes other health professional that you have [disease or asleep? with upper condition].” We defined self-reported CVD by an answer limit of 60 of yes to any of coronary artery disease, angina, myocardial infarction, stroke, or congestive heart Frequent In the past failure. We defined hypertension by self-report or by daytime month, how Never, sleepiness often did you measured blood pressure of 140/90 mm Hg or higher. rarely (1 feel excessively We defined depressive symptoms by at least 5 positive time/mo), or overly responses on the PHQ-9, along with reported functional sometimes sleepy during impairment. We calculated estimated glomerular (2-4 the day? times/mo), Often/almost filtration rate (eGFR) according to the Modification of often (5-15 always Diet in Renal Disease equation for isotope dilution mass Frequent In the past times/mo), spectrometry traceable creatinine (18). We defined sleeping month, how almost albuminuria by a single urinary albumin:creatinine ratio pill use often did you always (16- take sleeping of 30 mg/g or more. 30 pills or other times/mo) medication to Statistical analysis help you sleep? We compared selected characteristics for participants with and without diabetes using χ2 tests for categorical Apnea In the past 12 Never, months, how rarely (1-2 variables and t tests for continuous variables. We often did you nights/wk), calculated prevalence of sleep problems by diabetes snort, gasp, or occasionally classification. We used multivariable logistic regression stop breathing (3-4 to obtain adjusted odds ratios (ORs) and 95% Often/almost while you were nights/wk), confidence intervals (CIs); covariates were chosen both always or sleeping? frequently for evidence of confounding and for parsimony. We (≥5 yes and performed sensitivity analyses with different definitions nights/wk) sleep apnea of diabetes among those not reporting sleeping pill use, Have you ever Yes, no with further covariates, and stratified by possible effect been told by a modifiers. All analyses were performed using Stata doctor or other health Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 4 of 12 version 10.0 (StataCorp LP, College Station, Texas) to professional account for study design weights, strata, and primary that you have sampling units. a sleep disorder? Results What was the Sleep sleep disorder? apnea, Characteristics of US population by insomnia, diabetes status restless legs, other Participants with diabetes were older and more likely to be non-Hispanic black, to have no high school diploma, Nocturiab During the past Any ≥2 and to be insured than those without diabetes (Table 1). 30 days, how number episodes/ Relative to their counterparts, those with diabetes were many times with upper night less likely to be daily smokers, drank fewer alcoholic per night did limit of 5 you most beverages per week, and were more likely to have typically get up obesity, depression, hypertension, cardiovascular to urinate, disease, albuminuria, and reduced kidney function and from the time to use diuretics (Table 1). you went to bed at night Prevalence of sleep problems until the time Overall, 93% of the adult US population reported at you got up in least 1 of the problems examined (Table 2). Leg the morning? symptoms (41%), inadequate sleep (37%), severe sleep Leg In the past Never, deprivation (29%), and nocturia (25%) were the most symptoms month, how rarely (1 commonly reported problems. While frequent sleeping often did you time/mo), pill use and apnea were less commonly reported, nearly have leg jerks sometimes 1 in 10 reported either. Those with diabetes were more while trying to (2-4 likely than those without diabetes to report multiple sleep? times/mo), sleep problems (mean no. of problems, 3.1 vs 2.5; often (5-15 In the past Figure). times/mo), month, how almost often did you always (16- have leg 30 cramps while trying to sleep? times/mo) Often/almost always or Have you ever Yes, no yes and been told by a restless legs doctor or other health professional that you have a sleep disorder? What was the Sleep sleep disorder? apnea, insomnia, restless legs, other Abbreviation: NHANES, National Health and Nutrition Examination Survey. a Adapted by NHANES from the Sleep Heart Study Sleep Habits Questionnaire. b From kidney conditions – urology questionnaire of NHANES. Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 5 of 12 Figure. Number of reported sleep problems by diabetes status. The mean number of problems was 2.5 for the no- diabetes group and 3.1 for the diabetes group. Differences between the 2 groups were significant at P < .001 in terms of both percentage distribution and mean number of problems (calculated by using χ2 and t tests, respectively). [A tabular version of this figure is also available.] Association of sleep problems with diabetes Diabetes was associated with increased odds of inadequate sleep, frequent daytime sleepiness, restless legs symptoms, sleep apnea, and nocturia (Table 3). These associations were generally robust after adjustment for confounding factors. The magnitude of the associations of sleep apnea and, to a slightly lesser extent, inadequate sleep with diabetes was attenuated by adjustment for BMI but remained significant. The associations of diabetes with daytime sleepiness and inadequate sleep were rendered nonsignificant with the final adjustment for alcohol use. Sensitivity analyses examining the association of sleep problems with diabetes defined only by glycohemoglobin showed similar results, except that the association between glycohemoglobin and sleep apnea was fully explained by BMI (data not shown). Results with diabetes defined by self-report, glychohemoglobin, and fasting plasma glucose were nearly identical to our primary analyses. When diabetes was examined by severity category (no diabetes, diabetes with glycohemoglobin <7.5%, diabetes with glycohemoglobin >7.5%), apnea, leg symptoms, daytime sleepiness, and nocturia (but not inadequate sleep) all showed greater odds with increasing severity in a significant, graded fashion. Diabetes duration was significantly associated with the same problems; risk increased 20% to 30% per 10 years since diagnosis. Furthermore, the associations of diabetes with sleep problems were also similar among the subset of the population not reporting sleeping pill use (data not shown). Adjustment for other possible confounders generally did not substantially change the results: waist circumference was associated with sleep apnea (per 1-cm increase: OR, 1.03; 95% CI, 1.02- 1.05), but its addition to the model did not alter the association of diabetes with apnea (OR, 1.41; 95% CI, 1.02-1.95). Similarly, the association of diabetes with nocturia was not affected by either pulse pressure (OR, 1.48; 95% CI, 1.20- 1.84) or systolic blood pressure (OR, 1.48; 95% CI, 1.19-1.83). Higher income was generally associated with lower prevalence of sleep problems (with the exception of apnea, which showed the opposite association for the highest income category); however, its addition to the models did not affect the association of diabetes with sleep problems. Stratified analyses showed that the association of sleep apnea, leg symptoms, and nocturia with diabetes was strongest among participants younger than 60 years old compared to those 60 or older (leg symptoms: OR, 1.94 vs 1.24; P = .006; apnea: OR, 3.52 vs 1.59; P < .001; and nocturia: OR, 3.09 vs 1.55; P < .001) (data not shown). The association of leg symptoms with diabetes was stronger among women than men (OR, 1.65 vs 1.28; P = .04). This effect modification by age and sex was not significant for any other sleep problem, and race/ethnicity did not modify the effect of these associations. Discussion We found that sleep problems are highly prevalent in the United States. More than 90% of NHANES respondents reported any examined sleep problem and 10% to 40% reported any given problem. Inadequate sleep, frequent daytime Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 6 of 12 sleepiness, apnea, leg symptoms, and nocturia were all more common among those with diabetes than those without diabetes. These associations persisted after adjustment for conditions that could contribute to poor sleep and were generally strongest among respondents who were younger and female. Although frequent sleeping pill use and severe sleep deprivation were both common, the prevalence of these problems did not differ by diabetes status. The association of diabetes with sleep apnea, which was independent of obesity — a risk factor for both conditions — has been shown previously (10), as has our observed association between diabetes and restless legs symptoms (19), which may have neuropathic origins or be related to commonly used medications such as second-generation antidepressants and antihistamines. However, less is known about other sleep problems among people with diabetes. We found that nocturia and excessive sleepiness were also independently associated with diabetes. Nocturia was the most common sleep problem reported in this population, and the association with diabetes persisted even after adjustment for diuretic use. Nocturia is often not considered among the common sleep problems, but it may have deleterious effects on both sleep and quality of life (20), which was not assessed in this study. Inadequate sleep and excess sleepiness are similarly under-recognized (21) and detrimental to physical and mental health. Although we have shown that diabetes is independently associated with increased risk of several sleep problems, the cross-sectional study design precludes causal inference, despite the magnitude and dose-response nature of the observed associations. Additionally, while we found that duration of diabetes was positively associated with increased risk of apnea, nocturia, leg symptoms, and daytime sleepiness — suggesting a possible temporal relationship between diabetes and subsequent sleep problems — we cannot definitively establish the directionality of the association. Previous research examining potential causal links between diabetes and sleep problems has been inconclusive. For example, a small study showed that forced sleep deprivation in healthy young men led to decreased leptin levels and increased appetite (22); another cross-sectional analysis of participants in the Sleep Heart Health Study showed that impaired glucose tolerance was more common among people with habitual sleep restriction (23), suggesting that sleep problems may lead to diabetes via physiologic mechanisms. However, the prevalence of sleep problems among patients with type 1 diabetes was found to be similar to that seen in type 2 diabetes (24). Given the difference in etiology, these results suggest that diabetes may also lead to sleep problems. Other limitations of note include the self-report of sleep problems, which is subject to recall and detection bias. Data for neuropathy or chronic pain, pruritis, caffeine use, neck circumference, and 24-hour blood pressure were not available in the surveys analyzed. Restless legs symptoms may not be limited to leg cramps or jerks. Sleep studies were not performed. Although we were able to show that adjustment for income did not affect the association between diabetes and sleep problems, we did not have data on poverty-related stressors. Such stressors are thought to increase the “allostatic load” and both interfere with sleep and increase risk for chronic diseases such as diabetes (25). However, our study also augments previous research on diabetes and sleep problems in several ways. It is a large, nationally representative study examining a comprehensive range of sleep problems, regardless of diagnosis. We were able to compare prevalence among people with diabetes to that of similar people without diabetes, to determine whether diabetes had an independent effect on sleep problems after adjustment for other factors strongly related to both diabetes and sleep, including age, sex, obesity, cardiovascular disease, depression, kidney disease, alcohol use, and income. In conclusion, people with diabetes are more likely to have sleep problems than their counterparts of the same age, sex, and race/ethnicity without diabetes, regardless of several behaviors and comorbid conditions that could interfere with sleep. Because sleep problems and diabetes are both associated with poor quality of life (5,8), further research is warranted. Such efforts should examine the possibly dual directionality of the association of diabetes and sleep problems and explore possible causal inference and associated outcomes such as quality of life, ideally in a longitudinal cohort. Our results suggest that diabetes patients should be screened for these treatable sleep problems (sleep apnea, insomnia, restless legs, and nocturia). Recognition and treatment of sleep problems, particularly in the disproportionately affected younger and female diabetes populations, could considerably improve quality of life and, possibly, clinical outcomes among these patients. Acknowledgments We thank the participants and staff of the NHANES survey and Seena Nair for her assistance with preparation of tables. This publication was supported by Cooperative Agreement no. 5U58DP002007-02 (Collaborative Chronic Disease, Health Promotion and Surveillance Program) from CDC. Author Information Corresponding Author: Laura Plantinga, ScM, Department of Epidemiology, Rollins School of Public Health, Emory University, Claudia Nance Rollins Building, Floor 3, 1518 Clifton Rd NE, Atlanta, GA 30322. Telephone: 404-727-8710. E-mail: Medscape CME Activity - CDC - Preventing Chronic Disease: Volume 9, 2012: 11_0244 Page 7 of 12 Vulnerable Populations, San Francisco General Hospital, San Francisco, California, and the Division of General Internal Medicine, University of California, San Francisco, California. Author Affiliations: Madhu N. Rao, University of California, San Francisco, California. Dean Schillinger, San Francisco General Hospital, San Francisco, California; University of California, San Francisco, California; and California Department of Public Health, Sacramento, California. References 1. Colten HR, Altevogt BM. Sleep disorders and sleep deprivation: an unmet public health problem. Washington (DC): Institute of Medicine; 2006. 2. Ayas NT, White DP, Manson JE, Stampfer MJ, Speizer FE, Malhotra A, Hu FBl. A prospective study of sleep duration and coronary heart disease in women. Arch Intern Med 2003;163(2):205-9. 3. Strine TW, Chapman DP. Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Med 2005;6(1):23-7. 4. Connor J, Norton R, Ameratunga S, Robinson E, Civil I, Dunn R, et al. Driver sleepiness and risk of serious injury to car occupants: population based case control study. BMJ 2002;324(7346):1125. 5. Verster JC, Pandi-Perumal SR, Streiner D. Sleep and quality of life in clinical medicine. 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American Diabetes Association. Standards of medical care in diabetes — 2011. Diabetes Care 2011;34 Suppl 1:S11-61. 18. Selvin E, Manzi J, Stevens LA, Van Lente F, Lacher DA, Levey AS, et al. Calibration of serum creatinine in the National Health and Nutrition Examination Surveys (NHANES) 1988-1994, 1999-2004. Am J Kidney Dis 2007;50(6):918-26. 19. Cuellar NG, Ratcliffe SJ. Restless legs syndrome in type 2 diabetes: implications to diabetes educators. Diabetes Educ 2008;34(2):218-34. 20. Ancoli-Israel S, Bliwise DL, Norgaard JP. The effect of nocturia on sleep. Sleep Med Rev 2011;15(2):91-7. 21. Roth T, Bogan RK, Culpepper L, Doghramji K, Doghramji P, Drake C, et al. Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management. Curr Med Res Opin 2010;26 Suppl 2:S3-24; quiz S25-7. 22. Spiegel K, Tasali E, Penev P, Van Cauter E. 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Characteristics of the US Adult Population, Overall and by Diabetes Status, NHANES, 2005-2008 Diabetes Status, % (95% CI) Total % (95% CI)a (N No Diabetes (n = Diabetes (n = P Characteristic = 9,848) 8,424) 1,424) Valueb Demographics Mean age, y (95% CI) 46.7 (45.8-47.5) 45.5 (44.7-46.4) 58.9 (57.7-60.1) <.001 Sex Male 48.0 (47.1-48.9) 47.9 (47.0-49.0) 48.5 (44.8-52.2) .77 Female 52.0 (51.1-52.9) 52.1 (51.1-53.0) 51.5 (47.8-55.2) Race/ethnicityc Non-Hispanic white 71.4 (66.5-75.8) 72.4 (67.7-76.6) 62.6 (54.2-70.3) Non-Hispanic black 10.7 (8.3-13.7) 9.9 (7.6-12.8) 17.7 (13.6-22.8) <.001 Mexican American 8.2 (6.5-10.2) 8.1 (6.5-10.1) 8.8 (6.5-11.8) Socioeconomic status Education

Prevalence of Self-Reported Sleep Problems Among People

Similar Prevalence of Self-Reported Sleep Problems Among People